Subtitles and Transcript

Deborah Rhodes

0:11
There are two groups of womenwhen it comes to screening mammography --women in whom mammography works very welland has saved thousands of livesand women in whom it doesn't work well at all.Do you know which group you're in?If you don't, you're not alone.Because the breast has becomea very political organ.The truth has become lostin all the rhetoriccoming from the press, politicians,radiologistsand medical imaging companies.I will do my best this morningto tell you what I think is the truth.But first, my disclosures.I am not a breast cancer survivor.I'm not a radiologist.I don't have any patents,and I've never received any money from a medical imaging company,and I am not seeking your vote.

1:05
(Laughter)

1:07
What I amis a doctor of internal medicinewho became passionately interested in this topicabout 10 years agowhen a patient asked me a question.She came to see meafter discovering a breast lump.Her sister had been diagnosed with breast cancerin her 40s.She and I were both very pregnant at that time,and my heart just ached for her,imagining how afraid she must be.Fortunately, her lump proved to be benign.But she asked me a question:how confident was Ithat I would find a tumor early on her mammogramif she developed one?So I studied her mammogram,and I reviewed the radiology literature,and I was shocked to discoverthat, in her case,our chances of finding a tumor early on the mammogramwere less than the toss of a coin.

2:00
You may recall a year agowhen a firestorm eruptedafter the United States Preventive Services Task Forcereviewed the world's mammography screening literatureand issued a guidelinerecommending against screening mammogramsin women in their 40s.Now everybody rushed to criticize the Task Force,even though most of them weren't in anyway familiarwith the mammography studies.It took the Senate just 17 daysto ban the use of the guidelinesin determining insurance coverage.Radiologists were outragedby the guidelines.The pre-eminent mammographer in the United Statesissued the following quoteto the Washington Post.The radiologists were, in turn, criticizedfor protecting their own financial self-interest.But in my view,the radiologists are heroes.There's a shortage of radiologistsqualified to read mammograms,and that's because mammograms are one of the most complexof all radiology studies to interpret,and because radiologistsare sued more oftenover missed breast cancerthan any other cause.But that very fact is telling.

3:16
Where there is this much legal smoke,there is likely to be some fire.The factor most responsible for that fireis breast density.Breast density refers to the relative amount of fat --pictured here in yellow --versus connective and epithelial tissues --pictured in pink.And that proportionis primarily genetically determined.Two-thirds of women in their 40shave dense breast tissue,which is why mammography doesn't work as well in them.And although breast density generally declines with age,up to a third of womenretain dense breast tissuefor years after menopause.

3:59
So how do you know if your breasts are dense?Well, you need to read the detailsof your mammography report.Radiologists classify breast densityinto four categoriesbased on the appearance of the tissue on a mammogram.If the breast is less than 25 percent dense,that's called fatty-replaced.The next categoryis scattered fibroglandular densities,followed by heterogeneously denseand extremely dense.And breasts that fall into these two categoriesare considered dense.The problem with breast densityis that it's truly the wolf in sheep's clothing.Both tumors and dense breast tissueappear white on a mammogram,and the X-ray often can't distinguish between the two.So it's easy to see this tumorin the upper part of this fatty breast.But imagine how difficult it would beto find that tumor in this dense breast.That's why mammograms findover 80 percent of tumors in fatty breasts,but as few as 40 percent in extremely dense breasts.

5:01
Now it's bad enough that breast densitymakes it hard to find a cancer,but it turns outthat it's also a powerful predictorof your risk for breast cancer.It's a stronger risk factorthan having a mother or a sister with breast cancer.At the time my patient posed this question to me,breast density was an obscure topicin the radiology literature,and very few women having mammograms,or the physicians ordering them,knew about this.But what else could I offer her?

5:32
Mammograms have been around since the 1960's,and it's changed very little.There have been surprisingly few innovations,until digital mammography was approvedin 2000.Digital mammography is still an X-ray of the breast,but the imagescan be stored and manipulated digitally,just like we can with a digital camera.The U.S. has investedfour billion dollarsconverting to digital mammography equipment,and what have we gained from that investment?In a study funded by over 25 million taxpayer dollars,digital mammography was foundto be no better over allthan traditional mammography,and in fact, it was worse in older women.But it was better in one group,and that was women under 50who were pre-menopausal and had dense breasts,and in those women,digital mammography found twice as many cancers,but it still only found 60 percent.So digital mammographyhas been a giant leap forwardfor manufacturersof digital mammography equipment,but it's been a very small step forward forwomankind.

6:46
What about ultrasound?Ultrasound generates more biopsiesthat are unnecessary relative to other technologies,so it's not widely used.And MRI is exquisitely sensitive for finding tumors,but it's also very expensive.If we think about disruptive technology,we see an almost ubiquitous patternof the technology getting smaller and less expensive.Think about iPods compared to stereos.But it's the exact opposite in health care.The machines get ever biggerand ever more expensive.Screening the average young woman with an MRIis kind of like driving to the grocery store in a Hummer.It's just way too much equipment.One MRI scancosts 10 times what a digital mammogram costs.And sooner or later, we're going to have to accept the factthat health care innovationcan't always come at a much higher price.

7:45
Malcolm Gladwell wrote an article in the New Yorkeron innovation,and he made the case that scientific discoveriesare rarely the product of one individual's genius.Rather, big ideas can be orchestrated,if you can simply gatherpeople with different perspectives in a roomand get them to talk about thingsthat they don't ordinarily talk about.It's like the essence of TED.He quotes one innovator who says,"The only time a physician and a physicist get togetheris when the physicist gets sick."(Laughter)This makes no sense,because physicians have all kinds of problemsthat they don't realize have solutions.And physicists have all kinds of solutions for thingsthat they don't realize are problems.Now, take a look at this cartoonthat accompanied Gladwell's article,and tell me if you see something disturbingabout this depiction of innovative thinkers.

8:42
(Laughter)

8:44
So if you will allow me a little creative license,I will tell you the storyof the serendipitous collisionof my patient's problemwith a physicist's solution.Shortly after her visit,I was introduced to a nuclear physicistat Mayonamed Michael O'Conner,who was a specialist in cardiac imaging,something I had nothing to do with.And he happened to tell meabout a conference he'd just returned from in Israel,where they were talking about a new type of gamma detector.Now gamma imaging has been around for a long timeto image the heart,and it had even been tried to image the breast.But the problem wasthat the gamma detectorswere these huge, bulky tubes,and they were filled with these scintillating crystals,and you just couldn't get them close enough around the breastto find small tumors.But the potential advantage wasthat gamma rays, unlike X-rays,are not influenced by breast density.But this technologycould not find tumors when they're small,and finding a small tumor is critical for survival.If you can find a tumorwhen it's less than a centimeter,survival exceeds 90 percent,but drops off rapidlyas tumor size increases.But Michael told me abouta new type of gamma detector that he'd seen,and this is it.It's madenot of a bulky tube,but of a thin layer of a semiconductor materialthat serves as the gamma detector.And I started talking to himabout this problem with breast density,and we realized that we might be able to get this detectorclose enough around the breastto actually find small tumors.

10:27
So after putting togethera grid of these cubes with tape --(Laughter)-- Michael hacked off the X-ray plateof a mammography machinethat was about to be thrown out,and we attached the new detector,and we decided to call this machineMolecular Breast Imaging, or MBI.This is an image from our first patient.And you can see, using the old gamma technology,that it just looked like noise.But using our new detector,we could begin to see the outline of a tumor.

11:02
So here we were, a nuclear physicist,an internist,soon joined by Carrie Hruska, a biomedical engineer,and two radiologists,and we were trying to take onthe entrenched world of mammographywith a machine that was held together by duct tape.To say that we facedhigh doses of skepticismin those early yearsis just a huge understatement,but we were so convinced that we might be able to make this workthat we chipped away with incremental modificationsto this system.This is our current detector.And you can see that it looks a lot different.The duct tape is gone,and we added a second detector on top of the breast,which has further improved our tumor detection.

11:48
So how does this work?The patient receives an injection of a radio tracerthat's taken up by rapidly proliferating tumor cells,but not by normal cells,and this is the key difference from mammography.Mammography relies on differencesin the appearance of the tumor from the background tissue,and we've seen that those differencescan be obscured in a dense breast.But MBI exploitsthe different molecular behavior of tumors,and therefore, it's impervious to breast density.After the injection,the patient's breast is placed between the detectors.And if you've ever had a mammogram --if you're old enough to have had a mammogram --you know what comes next:pain.You may be surprised to knowthat mammography is the only radiologic studythat's regulated by federal law,and the law requiresthat the equivalent of a 40-pound car batterycome down on your breast during this study.But with MBI,we use just light, pain-free compression.(Applause)And the detectorthen transmits the image to the computer.

13:03
So here's an example.You can see, on the right, a mammogramshowing a faint tumor,the edges of which are blurred by the dense tissue.But the MBI image shows that tumor much more clearly,as well as a second tumor,which profoundly influence that patient's surgical options.In this example, although the mammogram found one tumor,we were able to demonstrate three discrete tumors --one is small as three millimeters.

13:29
Our big break came in 2004.After we had demonstrated that we could find small tumors,we used these imagesto submit a grant to the Susan G. Komen Foundation.And we were elated when they took a chanceon a team of completely unknown investigatorsand funded us to study1,000 women with dense breasts,comparing a screening mammogram to an MBI.Of the tumors that we found,mammography foundonly 25 percent of those tumors.MBI found 83 percent.Here's an example from that screening study.The digital mammogram was read as normaland shows lots of dense tissue,but the MBI shows an area of intense uptake,which correlated with a two-centimeter tumor.In this case, a one-centimeter tumor.And in this case,a 45-year-old medical secretary at Mayo,who had lost her mother to breast cancer when she was very young,wanted to enroll in our study.And her mammogram showed an area of very dense tissue,but her MBI showed an areaof worrisome uptake,which we can also see on a color image.And this correspondedto a tumor the size of a golf ball.But fortunately it was removedbefore it had spread to her lymph nodes.

14:50
So now that we knew that this technologycould find three times more tumors in a dense breast,we had to solve one very important problem.We had to figure out how to lower the radiation dose,and we have spent the last three yearsmaking modifications to every aspect of the imaging systemto allow this.And I'm very happy to report that we're now using a dose of radiationthat is equivalent to the effective dosefrom one digital mammogram.And at this low dose, we're continuing this screening study,and this image from three weeks agoin a 67-year-old womanshows a normal digital mammogram,but an MBI imageshowing an uptake that proved to be a large cancer.So this is not just young women that it's benefiting.It's also older women with dense tissue.And we're now routinely using one-fifth the radiation dosethat's used in any other type of gamma technology.

15:44
MBI generates four images per breast.MRI generates over a thousand.It takes a radiologistyears of specialty trainingto become expert in differentiatingthe normal anatomic detailfrom the worrisome finding.But I suspect even the non-radiologists in the roomcan find the tumor on the MBI image.But this is why MBIis so potentially disruptive --it's as accurate as MRI,it's far less complex to interpret,and it's a fraction of the cost.But you can understand why there may beforces in the breast-imaging worldwho prefer the status quo.

16:25
After achieving what we felt were remarkable results,our manuscript was rejectedby four journals.After the fourth rejection,we requested reconsideration of the manuscript,because we strongly suspectedthat one of the reviewers who had rejected ithad a financial conflict of interestin a competing technology.Our manuscript was then acceptedand will be published later this monthin the journal Radiology.(Applause)We still need to complete the screening study using the low dose,and then our findings will need to be replicatedat other institutions,and this could take five or more years.If this technology is widely adopted,I will not benefit financially in any way,and that is very important to me,because it allows me to continue to tell you the truth.But I recognize --(Applause)I recognize that the adoption of this technologywill depend as much on economicand political forcesas it will on the soundness of the science.

17:40
The MBI unit has now been FDA approved,but it's not yet widely available.So until something is availablefor women with dense breasts,there are things that you should knowto protect yourself.First, know your density.Ninety percent of women don't,and 95 percent of women don't knowthat it increases your breast cancer risk.The State of Connecticut became the first and only stateto mandate that women receive notificationof their breast densityafter a mammogram.I was at a conference of 60,000 people in breast-imaginglast week in Chicago,and I was stunned that there was a heated debateas to whether we should be telling womenwhat their breast density is.Of course we should.And if you don't know, please ask your doctoror read the details of your mammography report.Second, if you're pre-menopausal,try to schedule your mammogramin the first two weeks of your menstrual cycle,when breast density is relatively lower.Third, if you notice a persistent change in your breast,insist on additional imaging.And fourth and most important,the mammography debate will rage on,but I do believe that all women 40 and oldershould have an annual mammogram.

18:58
Mammography isn't perfect,but it's the only test that's been provento reduce mortality from breast cancer.But this mortality banneris the very swordwhich mammography's most ardent advocates useto deter innovation.Some women who develop breast cancerdie from it many years later,and most women, thankfully, survive.So it takes 10 or more yearsfor any screening methodto demonstrate a reductionin mortality from breast cancer.Mammography's the only one that's been around long enoughto have a chance of making that claim.It is time for us to acceptboth the extraordinary successes of mammographyand the limitations.We need to individualize screeningbased on density.For women without dense breasts,mammography is the best choice.But for women with dense breasts;we shouldn't abandon screening altogether,we need to offer them something better.

19:59
The babies that we were carryingwhen my patient first asked me this questionare now both in middle school,and the answer has been so slow to come.She's given me her blessingto share this story with you.After undergoing biopsiesthat further increased her risk for cancerand losing her sister to cancer,she made the difficult decisionto have a prophylactic mastectomy.We can and must do better,not just in time for her granddaughtersand my daughters,but in time for you.